Sunday, May 7, 2017

How does social class
prejudice reveal itself in public health? Among conservatives it might be the
attitude that low income people deserve to be sicker, and we don’t need to help
them, because they are lazy. Liberals have their attitudes, too. For example,
“we are experts and know best what you poor folks need,” although that, too, is
often not true. I’ve been thinking about this in connection with public health
programs that just don’t work the way they should: transportation benefits that
people have too much trouble using, mental health coverage that is inadequate
for the problems many people face, cuts to programs that have worked well; and
yet public health tolerates these situations! Why? Let’s explore one concrete
example how social class works in public health: efforts to reduce tobacco
smoking.

Tobacco is the drug of choice
for low income Americans. For example in Gratiot County we found that 31
percent of adults who earn $20,000 or less smoke compared to 9 percent of
adults who earn $75,000 or more. Twenty-nine percent of mothers smoked while
pregnant! This is a really big deal. In another blogpost I wrote about how heart
disease deaths are increasing in rural Michigan.

Today, public health in
Michigan has two favorite ways to try to help people quit. First, you can sign
up to get friendly text messages that encourage you to keep trying; second,
Michigan like other states has jacked up taxes on cigarettes to high levels
(not high enough for some) in hopes of making smoking too expensive. You can
find lots of research that says these two approaches are effective in getting
people to quit, but they aren’t, at least among low income people. The reason
public health says texts and taxes get people to quit smoking is because that’s
all we’ve got left. Our general fund budgets are far less likely to support
tobacco cessation programs than they once were, and health insurance, including
Medicaid, doesn’t reimburse enough for us to support cessation programs by
billing insurances—but still, we want to be able to say we’re doing something.

But not everyone agrees. In “Poor Smokers, Poor Quitters, and Cigarette
Tax Regressivity” appearing in American Journal of Public Health, Dahlia
Remler found, “cigarette taxes heavily burden poor smokers who do not quit, no
matter how tax burden is assessed.” In another study in the Journal of Policy
Analysis and Management, Remler said, “Very high cigarette taxes, however, have
a dirty little secret: their regressivity. Overwhelmingly and increasingly,
smokers are concentrated among the poor. Moreover, our era of rising cigarette
taxes is also an era of dramatically rising income inequality and possibly
lower purchasing power for the poor.”

The
public health community has rallied behind the taxes. The Campaign for Tobacco
Free Kids says, somewhat snarkily, “it is smoking itself and its health harms
that are hurting the lower-income population,” not the taxes. Therefore the
Campaign is not responsible for the harms of the taxes. The social class bias
in this attitude is somewhat breathtaking. You can almost hear someone huffing
“if they are too stupid to quit, screw them.” The Campaign is a left-leaning
progressive public health organization, but here, their attitudes are similar,
for example, to Republicans in the House of Representatives who think it is OK
to get rid of health care benefits for low income people because they “made bad
choices.”

But evidence is mounting that
tobacco taxes are harmful to the poor. Katherine T. Hirono and Katherine Smith
published a review of the literature and concluded
that “very large cigarette tax increases unintentionally harm the most
vulnerable in society: smokers who are homeless, very low income, and/or suffer
from mental illness… Low-income smokers who either can't or won't kick the
habit following large tobacco tax increases face increased financial hardship,
and so do their families.”

But surely low income people
don’t give up food or other necessities just to keep smoking? Remember that tobacco is very addictive. A study by the Research Triangle
Institute showed that low-income smokers in New York, which had the nation's
highest state cigarette tax, spent nearly a quarter of their household income
on cigarettes. Nationally, those with the lowest incomes smoke less, but still
spend just over 14 percent.

In raising these issues, I
want to challenge my colleagues to think about how social class influences our
response to the unintended consequences of our liberal policies. In 1920, in
the face of rampant alcoholism, who could have imagined that prohibition would
cause alcohol-related mortality to soar out of control? But it did. But that
wasn’t the worst failure of public health at that time. The real failure was
refusing to support the repeal of prohibition once it was understood that the
law had made things worse. The public health community supported prohibition to
help people avoid the harms of excessive alcohol consumption, but couldn’t
change course even after it understood prohibition was making things
worse.

Yes, it bothers me that
Michigan’s Mackinac Center, which opposed the Affordable Care Act, also opposes
tobacco taxes. And I worry my musings may be mistaken when I see that my own
public health association, the Michigan Association for Local Public Health,
strongly supporting increased tobacco taxes. But we need to remember that real human
beings are the objects of our policy prescriptions. I remember meeting a low
income woman at a community event where Chantix, a drug that helps people quit,
was being distributed. She began crying. A tobacco cessation counselor hugged
her and said, “You’re afraid you won’t be able to quit” and the woman sobbed,
“I’ve tried so many times and nothing works.” I didn’t know people cried about
not being able to quit smoking until I saw it.

Think about this: it is
difficult to argue that we raise cigarette taxes because we really want to help
low income people quit, given that we do so little else to help them do so. If
we wanted to help people quit we would use the tax increases to address the
problems in people’s lives that keep them smoking. But we don’t. In Michigan we
have used tobacco tax revenue for things like scholarships, school aid and debt
service. I agree those things are important, but so little tobacco tax revenue
goes for smoking cessation in Michigan that the State gets a grade of F from the
American Lung Association for its paltry tobacco prevention efforts. The real
reason for the taxes is to plug budget holes, and we don’t lose sleep thinking
about the woman who spent her last dollar on cigarettes and doesn’t know what
she will eat tomorrow.